Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists

Checklists are common tools used in many industries. Unfortunately, their adoption in the field of medicine has been limited to equipment operations or part of specific algorithms. Yet they have tremendous potential to improve patient outcomes by democratizing knowledge and helping ensure that all patients receive evidence-based best practices and safe high-quality care. Checklist adoption has been slowed by a variety of factors, including provider resistance, delays in knowledge dissemination and integration, limited methodology to guide development and maintenance, and lack of effective technical strategies to make them available and easy to use. In this article, we explore some of the principles and possible strategies to further develop and encourage the implementation of checklists into medical practice. We describe different types of checklists using examples and explore the benefits they offer to improve care. We suggest methods to create checklists and offer suggestions for how we might apply them, using some examples from our own experience, and finally, offer some possible directions for future research.

An increase in mortality has been documented in association with paramedic rapid sequence intubation (RSI) of severely head-injured patients. This analysis explores the impact of hypoxia and hyperventilation on outcome. Adult severely head-injured patients (Glasgow Coma Scale score of 3-8) unable to be intubated without neuromuscular blockade underwent paramedic RSI using midazolam and succinylcholine; rocuronium was administered after confirmation of tube position. Standard ventilation parameters were used for most patients; however, one agency instituted use of digital end-tidal carbon dioxide (ETCO2) and oxygen saturation (Spo2) monitoring during the trial. Each patient undergoing digital ETCO2/Spo2 monitoring was matched to three historical nonintubated controls on the basis of age, gender, mechanism, and Abbreviated Injury Scale scores for each of six body regions. Logistic regression was used to explore the impact of oxygen desaturation during laryngoscopy and postintubation hypocapnia and hypoxia on outcome. The relationship between hypocapnia and ventilatory rate was explored using linear regression and univariate analysis. In addition, trial patients and controls were compared with regard to mortality and the incidence of "good outcomes" using an odds ratio analysis. Of the 426 trial patients, a total of 59 had complete ETCO2/Spo2 monitoring data; these were matched to 177 controls. Logistic regression revealed an association between the lowest ETCO2 value and final ETCO2 value and mortality. Matched-controls analysis confirmed an association between hypocapnia and mortality. A statistically significant association between ventilatory rate and ETCO2 value was observed (r = -0.13, p < 0.0001); the median ventilatory rate associated with the lowest recorded ETCO2 value was significantly higher than for all other ETCO2 values (27 mm Hg vs. 19 mm Hg, p < 0.0001). In addition, profound desaturations during RSI and hypoxia after intubation were associated with higher mortality than matched controls. Overall mortality was 41% for trial patients versus 22% for matched controls (odds ratio, 2.51; 95% confidence interval, 1.33-4.72; p = 0.004). Hyperventilation and severe hypoxia during paramedic RSI are associated with an increase in mortality.

Training requirements to perform safe prehospital endotracheal intubation (ETI) are not clearly known. This study aimed to determine differences in ETI performance between 'proficient performers' and 'experts' according to the Dreyfus & Dreyfus framework of expertise. As a model for 'proficient performers' EMS physicians with a clinical background in internal medicine were compared to EMS physicians with a background in anaesthesiology as a model for 'experts'. Over a one-year period all ETIs performed by the EMS physicians of our institution were prospectively evaluated. 'Proficient performers' and 'experts' were compared regarding incidence of difficult ETI, ability to predict difficult ETI, and decision for ETI. Mean years of professional experience were similar between the physician groups, but the median ETI experience differed significantly with 18/year for 'proficients' and 304/year for 'experts' (p<0.001). 'Proficient performers' intubated 130 of their 2170 treated patients (6.0%), while 'experts' did so in 146 of 1809 cases (8.1%, p=0.01 for difference). The incidence of difficult ETI was 17.7% for 'proficient performers', and 8.9% for 'experts' (p<0.05). In 4 cases ETI was impossible, all managed by 'proficient performers', but all patients could be ventilated sufficiently. Unexpected difficult ETI occurred in 6.1% for 'proficient performers', and 2.0% for 'experts' (p=0.08). In a prehospital setting 'expert' status was associated with a significantly lower incidence of 'difficult ETI' and a higher proportion of ETI decisions. In addition, ability to predict difficult ETI was higher, although non-significant. There was no difference in the incidence of impossible ventilation. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.